Liver, explant
=Introduction= Liver transplantation is performed for a variety of causes of end-stage liver disease and fulminant hepatic failure, and occasionally neoplasms of the liver and proximal extrahepatic biliary tree. Procedures for grossing liver explants will vary between institutions. The discussion below represents the high end of the spectrum, with extensive examination. Some practices may encourage less exhaustive sampling; after all, the person already has a diagnosis and has received definitive treatment. All specimens should be regarded as potentially infectious, and thus treated with the appropriate respect and following standard precautions. One section of non-neoplastic liver should be stained with the liver panel: trichome, reticulin, PAS-D and iron stains. The questions to be addressed are: #What is the nature of the liver disease? #Is there a tumor? If so, what is the stage, and is there vascular invasion? =Fresh Handling= #Before handling the specimen: ##Review any relevant radiology studies on the patient to determine if there are clinically evident lesions (usually hepatocellular carcinoma). If there are lesions, make note of them on the explant dictation form. ##Check the requisition to see if there is a TIPSS. If there is a TIPSS, use cut-proof gloves and/or extra caution. #Weigh & measure the overall dimensions of the liver. #Photograph both surfaces of the liver (overall view pictures). #Orient the specimen by identifying the four lobes (right, left, caudate and quadrate) (Figure 1 and Figure 2). Describe the overall appearance of the liver and its capsular surface (ie, nodular, wrinkled, smooth). Note any abnormalities on the capsular surface (e.g. tissue previously harvested, a visible or palpable mass). If tissue has been harvested, measure the defect. #Place the liver with the falciform ligament down on the table such that the right lobe is on your right, and the left lobe is on your left. The hilar surface should be facing you. #If there is a TIPS: The TIPS is typically located in the right hepatic vein. Using a scalpel, cut out a cylindrical “core” of liver around the TIPS. Do not try to remove the wires from the tissue. Place the TIPS with the associated liver tissue in a formalin-filled container. #Start dissecting the liver by removing the gallbladder. Describe and section the gallbladder as you would with a routine cholecystectomy specimen. #Locate the sutured structures in the hilar area. Take shave margins of any sutured structures. They can be submitted together in one cassette. ##NOTE: For livers explanted for primary sclerosing cholangitis, after taking the vascular and bile duct shaved margins, block out the entire hilum and serially section (breadloaf) the block. Submit all sections of the hilum, assuring no ties or staples are submitted. #Find the right, middle and left hepatic veins; submit shaved margins of these vessels (this will require you to include some surrounding liver tissue). #Slice the liver along the long axis (parallel to the cutting table) into 2-3 mm sections using a big knife. (the thinner the better). Use a long sharp knife and long sweeping motions to avoid knife-chatter artifact. Keep sections in order so that the liver can be reconstructed after sectioning to measure tumor in relation to other lesions. #If a lesion is identified: ##Photograph the lesion (low and high “magnification”). If there are multiple lesions, photograph each and all of them identified by number. ##Measure the lesion(s) and describe it (them). State if it seems grossly necrotic. ##Note where the lesion is/are as precisely as you can (e.g. mid right lobe, 2 cm from the falciform ligament, 1 cm from the capsular surface). If there is a dominant lesion, describe the relationship of the other lesions to the dominant one. ##If there is more than one lesion, note the distance between the lesions as best you can. ##Identify grossly evident vascular invasion and/or portal vein thrombi. #If NO gross lesions are identified, a photograph of one cut section must still be taken. #Place paper towels between slices to enhance formalin penetration, and fix the whole liver in formalin. =Grossing In= #Submit the margins you took off in the fresh state: gallbladder, hilar structures and portal vein margins. #Submit ~3 representative sections from the right lobe and ~2 from the left. Include one section of a large portal tract. One section of non-neoplastic liver should be stained with a liver panel of special stains (e.g., trichome, reticulin, PAS-D and iron). #If a tumor is present, submit 1 section/cm of tumor and (if local practice dictates) the entire rim of surrounding liver (vascular invasion is often found around the edge of HCCs). =Sample Dictation= The specimen is received fresh, labeled with the patient’s name and medical record number and designated “___________________________”. The specimen consists of a liver and attached gallbladder with a combined weight of ___________ grams. The liver measures ______x ______ x ______ cm. The gallbladder weighs _____ grams and measures ____ x _____ x ____ cm. The serosal surface is ____________ (smooth and glistening without defects or masses). The gallbladder contains approximately ____ cc of viscous bile and ________stones measuring up to _____ cm in diameter. The wall is ____ cm thick. The mucosal surface is __________ (e.g. velvety with no focal lesions). Representative sections of the gallbladder are submitted as _______. The external surface of the liver is ______________________________________________(tan and diffusely multinodular). The tied hilar structures are identified, and shave margins are submitted as _______. Additional hilar tissue is submitted as _____________. Subhilar tissue is submitted as ____________. The hepatic vein margins are submitted as: right- _______; middle-_________; left-___________. Serial sections of the hepatic parenchyma reveal the following lesions (e.g.): 1. There is a well circumscribed, lobulated, soft, red and green-brown lesion measuring 2 x 2 cm in the dome (right lobe) of the liver located 0.5 cm from the capsular surface. 2. There is a second well circumbscribed round soft green-yellow lesion measuring 1.0 x 1.0 x 0.5 cm in the left lobe located 3 cm from the capsular surface. Two sections of lesion #1, one including the capsule, are submitted as __. Lesion #2 is entirely submitted as __. Otherwise, the cut surface of the liver is ____________ (e.g. uniformly tan and multinodular). Representative sections of the hepatic parenchyma are submitted as: Right lobe - ____________; Left lobe - ____________; Caudate lobe - ____________. Liver panel special stains are pre-ordered on block __. Specimen #2 is designated "Donor gallbladder" and consists of a gallbladder measuring _ x _ x _ cm. It is received with a wall defect measuring _ cm. The serosal aspect appears unremarkable with no gross lesions. The gallblader is opened to reveal pink-tan velvety mucosa with no gross lesions. There are no stones. The wall is up to _ cm thick. Representative sections are submitted as _. Specimen #3 is designated "Time zero liver biopsy" and consists of _ core(s) of tan-brown tissue consistent with liver parenchyma measuring _ in length and _ cm in diameter. The specimen is entirely submitted as _, and liver panel special stains are pre-ordered. =Review and Signout= For reporting results of liver allograft biopsies (time zero in this case, or for example in a re-do liver transplant) and grading rejection you can refer to the following website: http://tpis.upmc.edu The diagnosis of rejection may be difficult as there may be multiple causes of liver dysfunction in these patients (ischemia, viral or drug induced hepatitis, biliary obstruction, other infections, etc.). It should be remembered that rejection is a primarily portal tract disease causing bile duct damage and loss while these other conditions usually cause primarily lobular changes. #Liver, ___ grams, hepatectomy: :Chronic hepatitis, ____ (e.g. mildly) active, consistent with viral hepatitis C, with ___ fibrosis (almost all explants will be "with cirrhosis"). #Liver, ___ grams, hepatectomy: :A. Hepatocellular carcinoma, X cm, (well, moderately, poorly) differentiated, no lymphovascular invasion identified. :B. Hepatic vein and porta hepatic margins free of tumor. :C. Status post TIPSS procedure. :D. Background liver showing chronic hepatitis, (in-, minimally, mildly, moderately, severely) active, consistent with viral hepatitis C with cirrhosis, see note. :E. Gallbladder with no specific pathologic change. #Gallbladder, donor cholecystectomy: :Gallbladder with no specific pathologic change. :Chronic cholecystitis (with cholelithiasis). #Liver, time zero biopsy: :Liver with no significant inflammation, steatosis or fibrosis, see note. In the note, discuss special stains. ---- Return to Gastrointestinal Grossing